Healthcare Provider Details

I. General information

NPI: 1568878221
Provider Name (Legal Business Name): TEJASI GHOLAP MD SC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/02/2014
Last Update Date: 07/02/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

901 CENTER ST SUITE 209
ELGIN IL
60120-2104
US

IV. Provider business mailing address

2350 COUNTY FARM LN
SCHAUMBURG IL
60194-4807
US

V. Phone/Fax

Practice location:
  • Phone: 847-429-1157
  • Fax:
Mailing address:
  • Phone: 414-736-7583
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number036125306
License Number StateIL

VIII. Authorized Official

Name: TEJASI GHOLAP
Title or Position: OWNER
Credential: MD
Phone: 414-736-7583